In utero exposure to antidepressant medication and neonatal and child outcomes: a systematic review.

OBJECTIVE: The aim of this study is to systematically review published studies, reporting outcomes to offspring following in utero exposure to antidepressant medications, which used an untreated depressed comparison group. METHODS: OVID, Scopus, EBSCO Collections, the Cochrane Library and Web of Science databases were searched for relevant publications published between January 1950 and May 2018 and a total of 188 potentially eligible studies were identified. RESULTS: Following review, 16 primary studies were eligible for inclusion. Antidepressant exposure was associated with an increased risk of lower gestational age, preterm birth, but not low birthweight or being small for gestational age compared to untreated depression. There is some evidence that congenital defects are associated with antidepressant use, particularly between cardiac defects and paroxetine use. There is conflicting evidence regarding neurodevelopment in offspring, with some reports of increased incidence of autistic spectrum disorders and depression, but also reports of no problems when measuring emotional symptoms, peer problems, conduct problems and hyperactivity-inattention scores. CONCLUSION: When compared with an untreated depressed group, antidepressant exposure was associated with adverse outcomes at birth, while there is insufficient data to determine whether the association between antidepressants and congenital defects or developmental disorders is a true association. However, although we compared treated vs. untreated depression there still may be residual confounding as an untreated depressed group is likely to have less severe depression.

A randomized controlled feasibility trial exploring partnered ballroom dancing for people with Parkinson's disease.

OBJECTIVE: To determine the feasibility of a Dance Centre delivering a programme of mixed dances to people with Parkinson's and identify suitable outcomes for a future definitive trial. DESIGN: A two-group randomized controlled feasibility trial. METHODS: People with Parkinson's were randomized to a control or experimental group (ratio 15:35), alongside usual care. In addition, participants in the experimental group danced with a partner for one hour, twice-a-week for 10 weeks; professional dance teachers led the classes and field-notes were kept. Control-group participants were given dance class vouchers at the end of the study. Blinded assessments of balance, mobility and function were completed in the home. Qualitative interviews were conducted with a subsample to explore the acceptability of dance. RESULTS: A total of 51 people with Parkinson's (25 male) with Hoehn and Yahr scores of 1-3 and mean age of 71 years (range 49-85 years), were recruited to the study. Dance partners were of similar age (mean 68, range 56-91 years). Feasibility findings focused on recruitment (target achieved); retention (five people dropped out of dancing); outcome measures (three measures were considered feasible, changes were recommended). Proposed sample size for a Phase III trial, based on the 6-minute walk test at six months was 220. Participants described dance as extremely enjoyable and the instructors were skilled in instilling confidence and motivation. The main organizational challenges for a future trial were transport and identifying suitable dance partners. CONCLUSION: We have demonstrated the feasibility of conducting the study through a Dance Centre and recommend a Phase III trial.

The circumstances of falls among people with Parkinson's disease and the use of Falls Diaries to facilitate reporting.

PURPOSE: Falls are common in Parkinson's disease (PD). Falls Diaries are one way of recording fall frequency and the surrounding circumstances; completing them encourages recall, and their content focuses intervention. We reviewed the diaries completed by people with PD during a randomized controlled trial (RCT) of fall prevention to ascertain the key circumstances surrounding falls. METHOD: We asked independently mobile, cognitively intact people with a diagnosis of PD to maintain a Falls Diary throughout a six-month RCT. We sent monthly diary sheets on which to answer questions about the 'Location', 'Fall-related activity', 'Perceived cause', 'Landing' and 'Consequences' of every fall. We coded responses and counted frequencies. RESULTS: Of the 142 RCT participants (mean age 72 years; mean years since diagnosis 8), 135 completed the trial and their diary. We excluded 11 (8%) for missing data and/or unintelligible writing. The 124 remaining diaries recorded 639 falls: 80% happened at home, commonly in bedrooms, living areas, kitchens and gardens. Fallers had been ambulant in 45% of events, standing in 32% and transferring in 21%. Six 'activity-cause combinations' accounted for 55% of falls (tripping 13%; freezing, festination and retropulsion 11%; and postural instability when bending or reaching 9%, transferring 8%, walking 7% and washing or dressing 7%). Misjudgement and distraction played a part in 12% of falls described. CONCLUSIONS: Of over 600 falls surveyed, most happened at home, provoked by postural instability, tripping and freezing. Environmental adaptation and cognitive training should be trialled in falls prevention in PD, plus or minus traditional movement rehabilitation. Most participants completed Falls Diaries successfully. We advocate diary use, with follow-up interviews, in research and clinically. People with handwriting difficulty may require a typed diary, proxy diarist or interview.

Fall frequency, predicting falls and participating in falls research: similarities among people with Parkinson's disease with and without cognitive impairment.

OBJECTIVE: We compared fall frequency and prediction among People with Parkinson's Disease (PwP) with and without cognitive impairment (CI); researchers sometimes overlook the former, concerned about consent, recall and adherence and differences in fall frequency and predictability. METHODS: We recruited 101 PwP from one clinic, used the Montreal Cognitive Assessment to measure CI, noted repeated falls recalled retrospectively over 12 months and evaluated 'repeated falls' and 'difficulty turning' as predictors of falls over three months. RESULTS: Participant median age was 76 years, and time since diagnosis 6 years. Of 40 participants without CI, 40% recalled falls and 55% fell during follow-up (1.9 (±3.8) falls/person), the sensitivity of fall history being 57% and of turning 36%. Of 36 participants with mild CI, 42% recalled falls and 42% fell during follow-up (1.2 (±1.8) falls/person), the sensitivity of fall history being 67% and of turning 69%. Of 25 participants with moderate CI, 60% recalled falls and 58% fell during follow-up (1.2 (±1.8) falls/person), the sensitivity of fall history being 71% and of turning 69%. CONCLUSIONS: Researchers need not exclude people with CI assuming falls are more frequent and less predictable than among those without. Fall rates (falls/person during follow-up) were similar among people with and without CI. Falls and difficulty turning were more sensitive predictors of falling in those with CI than those without: a simple mobility test may suggest an individual's risk of falling if a history is unavailable. Most PwP with moderate CI fall repeatedly: carer involvement facilitates their inclusion in research.

Anterior cricoid split, 1977-1987. Evolution of a technique.

Acquired subglottic stenosis is a well-documented complication of endotracheal intubation in infants. In past years, many of these patients required a tracheotomy for a period of years prior to laryngotracheal reconstruction. The anterior cricoid split procedure was developed as a method of treatment for severe laryngeal stenosis in infants and young children without resorting to a tracheotomy. An analysis of our institution's ten-year experience with 67 patients is presented, detailing the changes in surgical technique that have taken place over that time period. This is contrasted with alternative means of cricoid decompression advocated by other surgeons. Our review supports the efficacy of this procedure when there is strict adherence to certain criteria prior to the performance of the operation. Specifically, this operation should be restricted to neonates or young infants whose pathology is limited to the glottis and subglottis or both, and in whom there is adequate pulmonary reserve.

Nursing management of the child with a tracheotomy.

The management of medically fragile children with tracheotomies can be challenging to the pediatrician. This management includes the well child care for these children as well as coordination of the often complex care associated with the underlying condition. Various diseases exist that cause airway obstruction, respiratory failure, or chronic aspiration, necessitating tracheotomies. Tracheotomies require astute observation and skilled care to minimize complications.

Vocal cord paralysis following child abuse.

Otorhinologic manifestations of child abuse are infrequently reported in the literature. Three cases of vocal cord paralysis following child abuse are presented. The pathophysiology of vocal cord paralysis is reviewed as it relates to pediatric vocal cord paralysis. Recognition of the possibility of vocal cord paralysis in an abused child who suffers significant head trauma or a strangulation injury is necessary to insure a more rapid diagnosis and initiation of effective therapy more promptly.

Laryngotracheoplasty for subglottic stenosis in Down Syndrome children: the Cincinnati experience.

Previous studies from our institution have noted difficulties in the surgical repair of subglottic stenosis (SGS) in children with Down Syndrome. The objectives of this paper were to update our 15 year experience in the Down Syndrome patient population, compare our results with our overall series of laryngotracheoplasty for SGS, and to report on the increased incidence of posterior glottic stenosis (PGS) within this group of patients. Medical records of all children with SGS and Down Syndrome evaluated between 1982 and 1997 were reviewed for history of prior intubation, tracheotomy, gastroesophageal reflux disease (GERD), pre-operative SGS grade, and decannulation. From this review several conclusions have been drawn. First, the risk factors for SGS appear to be the same in the Down Syndrome group as the general population. Second, SGS continues to be more prevalent among children with Down Syndrome than among children in the general population. Third, we have now found a higher rate of PGS within these patients when compared to our overall series. Finally, it now seems that our decannulation rates in Down Syndrome children are approaching our overall series results.

The child with a tracheotomy: making home care work.

Successful tracheotomy home care in children includes safe care of the child; it should promote the child's normal growth and development, yet minimize deleterious effects to the family's functioning and integrity. Only through cooperation and hard work among all concerned parties can this goal be attained.

Practical aspects of pediatric tracheotomy care.

Infants and children who manifest respiratory distress secondary to congenital or acquired abnormalities of the airway pose a unique problem that frequently requires a tracheotomy to control the patient's airway. These tracheotomies often are required for extended periods of time. Skilled care and astute observation are essential for the care of these patients while in hospital and at home. Although many of the care concerns relate to nursing and social issues, the otolaryngologist must maintain an active role in the medical management and co-ordination of discharge. This paper provides the otolaryngologist with an outline of the hospital care required for the pediatric tracheotomy patient. Additionally, it offers the otolaryngologist a model program for discharge planning and follow-up for the pediatric tracheotomy patient in the community.